Healthcare Provider Details

I. General information

NPI: 1073781811
Provider Name (Legal Business Name): PILSEN-LITTLE VILLAGE COMMUNITY MENTAL HEALTH CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2008
Last Update Date: 02/14/2022
Certification Date: 02/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3113 W CERMAK RD
CHICAGO IL
60623-3449
US

IV. Provider business mailing address

3113 W CERMAK RD
CHICAGO IL
60623-3449
US

V. Phone/Fax

Practice location:
  • Phone: 773-277-3413
  • Fax: 773-257-0912
Mailing address:
  • Phone: 773-277-3413
  • Fax: 773-277-3517

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License NumberA-0155-0001-A
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License NumberA-0155-0001-A
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MR. FRANCISCO CISNEROS
Title or Position: EXECUTIVE DIRECTOR
Credential: MA, CADC
Phone: 773-579-0832